Six sigma approach to improve surgical site infections: A key variable

BACKGROUND: Nationally, post-operative infections are a primary patient safety concern. Surgical site infections (SSIs) are not a rare outcome, occurring with 2%-5% of clean extra-abdominal and up to 20% of intra-abdominal surgeries.1 Nationally, each SSI is estimated to increase length of stay by an average of 7 days and result in more than $3,000 in additional charges.2 Patients with an SSI are also five times more likely to be readmitted and two times as likely to expire.2 PROJECT: Through ongoing quality improvement and infection control monitoring, a trend in readmissions with post-operative infections was noted. A six sigma approach was used to determine contributing factors for SSI. In addition to educational and minor process changes, the primary change centered on the use of the forced air-warming device for abdominal hysterectomy procedures. In fact, after implementation, we found that this project built on the outcomes of a surgical site infection study conducted by Veterans Health Administration (VHA) in 2002.3 RESULTS: After providing staff education for process changes, monitoring both process and outcome indicators continued for more than a year. As the process indicators improved, SSI rates declined. The number of physicians returning monthly surgical line listings increased from 78.7% in 2003, to 94.6% in 2004. The median first patient temperature after post-op admission to the medical-surgical nursing unit increased from a range of 96.4°F–96.8°F to 97.1°F–97.6°F. Total abdominal hysterectomy (TAH) infections were reduced from 14 in January-September 2003, to 7 in January-September 2004. Infection rate was reduced from 5.0 to 2.07 per 100 TAH surgeries (p = 0.045). CONCLUSIONS: The six sigma approach successfully improved infection rates and can be applied to other infection control efforts. This approach not only reduced infection rates and resulted in better patient care, but also substantiated research about patient temperature and SSIs. In particular, many organizations may find opportunities associated with the use of forced air-warming devices based on both our project results and the VHA study results.